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Mohamed SA, Adlung A, Ludwig NK, Samartzi M, Schad LR, Fatar M, Neumaier-Probst E. Temporal and Spatial Dynamics of Ischemic Stroke Lesions after Acute Therapy: A Comprehensive Edema Assessment Using Combined 1H- and 23Na-MRI. Cerebrovasc Dis 2024:1-11. [PMID: 39053442 DOI: 10.1159/000540162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 06/14/2024] [Indexed: 07/27/2024] Open
Abstract
INTRODUCTION Ischemic cerebral stroke initiates a complex cascade of pathophysiological events, involving various forms of molecular shifts and edema. Early intervention is pivotal in minimizing tissue loss and improving clinical outcomes. This study explores the temporal and spatial evolution of tissue sodium concentration (TSC) in acute ischemic lesions after acute therapy using 23Na-MRI in addition to conventional 1H-MRI. METHODS Prospectively, from examined 58 patients with acute ischemic stroke with a combined 1H/23Na-MRI within 72 h of symptom onset after receiving acute therapy, 31 patients were included in the evaluation of this study. After co-registration of the 23Na-MRI images to the morphological 1H-MRI images, manual segmentation of the ischemic lesions was performed, and the ADC and TSC measurements were quantified and correlated with the time of onset and lesion volume. RESULTS The mean TSC in ischemic lesions correlated positively with lesion volume (r = 0.52, p = 0.002) and showed a significant association with the time of stroke onset (r = 0.8, p < 0.001). Patients who were treated only with intravenous rtPA showed homogenous sodium signal intensity in the ischemic lesions, whereas the patients who received mechanical recanalization exhibited distinctive sodium signal intensity patterns with focal significant TSC differences. CONCLUSION The integration of 1H- and 23Na-MRI provides a nuanced understanding of temporal and spatial changes due to different types of edema in ischemic stroke lesions following acute treatment. Further exploration of these findings may enhance our understanding of stroke pathophysiology and guide personalized therapeutic interventions.
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Affiliation(s)
- Sherif A Mohamed
- Department of Neuroradiology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Anne Adlung
- Department of Computer Assisted Clinical Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University Grossman School of Medicine, New York, New York, USA
| | - Nadia K Ludwig
- Department of Computer Assisted Clinical Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Löwenstein Medical Technology, Karlsruhe, Germany
| | - Melina Samartzi
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany
| | - Lothar R Schad
- Department of Computer Assisted Clinical Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Marc Fatar
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Eva Neumaier-Probst
- Department of Neuroradiology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Frias P, Khangura RS, Varjavand B, Alexander MD. Imaging in acute ischaemic stroke: assessing findings in light of evolving therapies. Br J Radiol 2024; 97:1078-1087. [PMID: 38490240 PMCID: PMC11135800 DOI: 10.1093/bjr/tqae050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 03/17/2024] Open
Abstract
Acute ischaemic stroke (AIS) is a debilitating disease for which effective therapies are now available. Effective identification of candidates for therapy relies heavily on noninvasive imaging that must be interpreted accurately in a short timeframe. This review summarizes the evolution of AIS therapies and the implications for noninvasive imaging. The review concludes with consideration of longstanding assumptions about imaging of ischaemic stroke and potential paradigm shifts on the horizon.
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Affiliation(s)
- Patrick Frias
- Departments of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT 84132, United States
| | - Rajkamal S Khangura
- Neurointerventional Radiology, Sutter Sacramento Medical Center, Sacramento, CA 95816, United States
| | - Bahram Varjavand
- Neurointerventional Radiology, Sutter Sacramento Medical Center, Sacramento, CA 95816, United States
| | - Matthew D Alexander
- Departments of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT 84132, United States
- Neurointerventional Radiology, Sutter Sacramento Medical Center, Sacramento, CA 95816, United States
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Li P, Lu H, Shi X, Yan J, Zhou L, Yang J, Wang B, Zhao Y, Liu L, Zhu Y, Xu L, Yang X, Su X, Yang Y, Zhang T, Guo L, Liu X. Protective effects of human urinary kallidinogenase against corticospinal tract damage in acute ischemic stroke patients. Neuroreport 2024; 35:431-438. [PMID: 38526971 DOI: 10.1097/wnr.0000000000002028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
This study aimed to assess the effects of human urinary kallidinogenase (HUK) on motor function outcome and corticospinal tract recovery in patients with acute ischemic stroke (AIS). This study was a randomized, controlled, single-blinded trial. Eighty AIS patients were split into two groups: the HUK and control groups. The HUK group was administered HUK and standard treatment, while the control group received standard treatment only. At admission and discharge, the National Institutes of Health Stroke Scale (NIHSS), Barthel Index (BI) and muscle strength were scored. The primary endpoint was the short-term outcomes of AIS patients under different treatments. The secondary endpoint was the degree of corticospinal tract fiber damage under different treatments. There was a significant improvement in the NIHSS Scale, BI and muscle strength scores in the HUK group compared with controls (Mann-Whitney U test; P < 0.05). Diffusion tensor tractography classification and intracranial arterial stenosis were independent predictors of short-term recovery by linear regression analysis. The changes in fractional anisotropy (FA) and apparent diffusion coefficient (ADC) decline rate were significantly smaller in the HUK group than in the control group ( P < 0.05). Vascular endothelial growth factor (VEGF) increased significantly after HUK treatment ( P < 0.05), and the VEGF change was negatively correlated with changes in ADC. HUK is beneficial for the outcome in AIS patients especially in motor function recovery. It may have protective effects on the corticospinal tract which is reflected by the reduction in the FA and ADC decline rates and increased VEGF expression. The study was registered on ClinicalTrials.gov (unique identifier: NCT04102956).
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Affiliation(s)
- Peifang Li
- Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang
- Department of Neurology, Handan Central Hospital, Handan
| | - Honglin Lu
- Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang
| | - Xiaoman Shi
- Department of Pediatrics, Affiliated Hospital of Hebei University, Baoding
| | - Jiajia Yan
- Department of Neurology, Cangzhou Integrated Traditional Chinese and Western Medicine Hospital, Cangzhou
| | - Lixia Zhou
- Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang
| | - Jipeng Yang
- Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang
| | - Binbin Wang
- Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang
| | - Yanying Zhao
- Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang
| | - Luji Liu
- Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang
| | - Yipu Zhu
- Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang
| | - Lei Xu
- Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang
| | - Xiaoli Yang
- Department of Neurology, Hebei University of Engineering School of Medicine, Handan
| | - Xudong Su
- Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang
| | - Yi Yang
- Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang
| | - Tong Zhang
- Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang
| | - Li Guo
- Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang
| | - Xiaoyun Liu
- Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang
- Department of Neurology, the First Hospital of Hebei Medical University, Shijiazhuang, China
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Wang J, Wang T, Yang B, Chen Y, Gao P, Wang Y, Chen J, Chen F, Luo J, Yang R, Min X, Ma Y, Jiao L. Impact of acute silent ischemic lesions on clinical outcomes of carotid revascularization. Int J Surg 2024; 110:974-983. [PMID: 38052025 PMCID: PMC10871655 DOI: 10.1097/js9.0000000000000925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/09/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Previous literature has established an association between acute silent ischemic lesions (ASILs) and elevated susceptibility to future adverse clinical outcomes. The present study endeavors to scrutinize the prognostic significance of preprocedural ASILs, as detected through diffusion-weighted imaging and apparent diffusion coefficient metrics, in relation to subsequent adverse events-namely, stroke, myocardial infarction, and all-cause death-following carotid revascularization in a cohort of patients with symptomatic carotid stenosis. MATERIALS AND METHODS Subjects were extracted from a comprehensive retrospective dataset involving symptomatic carotid stenosis cases that underwent carotid revascularization at a tertiary healthcare institution in China, spanning January 2019 to March 2022. Of the 2663 initially screened patients (symptomatic carotid stenosis=1600; asymptomatic carotid stenosis=1063), a total of 1172 individuals with symptomatic carotid stenosis were retained for subsequent analysis. Stratification was implemented based on the presence or absence of ASILs. The primary endpoint constituted a composite measure of in-hospital stroke, myocardial infarction, or all-cause death. Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) treatment modalities were individually subjected to propensity score-matched analyses. RESULTS Among the 584 subjects who underwent CEA, 91 ASIL-positive and 91 ASIL-negative (NASIL) cases were propensity score-matched. Notably, the ASIL cohort demonstrated a statistically significant augmentation in the risk of primary outcomes relative to the NASIL group [10.99 vs. 1.10%; absolute risk difference, 9.89% (95% CI: 3.12-16.66%); RR, 10.00 (95% CI: 1.31-76.52); P =0.01]. Similarly, within the 588 CAS-treated patients, 107 ASIL-positive and 107 NASIL cases were matched, revealing a correspondingly elevated risk of primary outcomes in the ASIL group [9.35 vs. 1.87%; absolute risk difference, 7.48% (95% CI: 1.39-13.56%); RR, 5.00 (95% CI: 1.12-22.28); P =0.02]. CONCLUSIONS ASILs portend an elevated risk for grave adverse events postcarotid revascularization, irrespective of the specific revascularization technique employed-be it CEA or CAS. Thus, ASILs may serve as a potent biomarker for procedural risk stratification in the context of carotid revascularization.
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Affiliation(s)
- Jie Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University
- Department of Neurosurgery, Jinan Hospital of Xuanwu Hospital, Shandong First Medical University, Jinan
| | - Bin Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University
| | - Yanfei Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University
| | - Peng Gao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University
- Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing
| | - Yabin Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University
| | - Jian Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University
| | | | - Jichang Luo
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University
| | - Renjie Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University
| | - Xiaoli Min
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital, Kunming Medical University, Kunming, Peoples Republic of China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University
- Department of Neurosurgery, Jinan Hospital of Xuanwu Hospital, Shandong First Medical University, Jinan
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Zhang Z, Xu Q, Li J, Zhang C, Bai Z, Chai X, Xu K, Xiao C, Chen F, Liu T, Gu H, Xing W, Lu G, Zhang Z. MRI features of neuronal intranuclear inclusion disease, combining visual and quantitative imaging investigations. J Neuroradiol 2023:S0150-9861(23)00245-6. [PMID: 37758172 DOI: 10.1016/j.neurad.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/08/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE To observe the radiological characteristics of Neuronal Intranuclear Inclusion Disease (NIID) on lesion locations and diffusion property using quantitative imaging analysis. METHODS Visual inspection and quantitative analyses were performed on MRI data from 31 retrospectively included patients with NIID. Frequency heatmaps of lesion locations on T2WI and DWI were generated using voxel-wise analysis. Gray matter volume (GMV), white matter volume (WMV) and diffusion property of apparent diffusion coefficient (ADC) values of patients were voxel-wisely compared with healthy controls. Moreover, the ADC values within the DWI-detected lesion were compared with those within the adjacent cortical gray matter and white matter. Voxel-based lesion symptom mapping (VLSM) techniques, were used to determine the relationship between DWI lesion location and disease durations. RESULTS By visual inspection on the imaging findings, we proposed an "cockscomb flower sign" for describing the radiological feature of DWI hyperintensity within the corticomedullary junction. A "T2WI-DWI mismatch of spatial distribution" pattern was also revealed with visual inspection and frequency heatmaps, for describing the feature of a wider lesion distribution covering white matter shown on T2WI than that on DWI. Voxel-based morphometry comparison revealed that wildly reduced GMV and WMV, both the lesion areas detected by DWI and T2WI demonstrated ADC increase in patients. Furthermore, the ADC values within the DWI-detected lesion were intermediate between the adjacent cortex and the deep white matter with highest ADC. VLSM analysis revealed that frontal lobe, parietal lobe and internal capsule damage were associated with higher NIID durations. CONCLUSION NIID features with "cockscomb flower-like" DWI hyperintensity in area of corticomedullary junction, based on a "T2WI-DWI mismatch of spatial distribution" of lesion locations. The pathological substrate of corticomedullary junction hyperintensity on DWI, can not be explained as diffusion restriction. These typical radiological features of brain MRI would be helpful for diagnosis of NIID.
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Affiliation(s)
- Zixuan Zhang
- Department of Diagnostic Radiology, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, China; School of Medical Imaging, Xuzhou Medical University, Xuzhou 221004, China
| | - Qiang Xu
- Department of Diagnostic Radiology, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, China
| | - Jianrui Li
- Department of Diagnostic Radiology, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, China
| | - Chao Zhang
- School of Medical Imaging, Xuzhou Medical University, Xuzhou 221004, China; Department of Medical Imaging, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221004, China
| | - Zhuojie Bai
- Department of Medical Imaging, Nanjing Jiangbei Hospital, Nanjing 210000, China
| | - Xue Chai
- Department of Medical Imaging, Nanjing Brain Hospital, Nanjing 210029, China
| | - Kai Xu
- School of Medical Imaging, Xuzhou Medical University, Xuzhou 221004, China; Department of Medical Imaging, Affiliated Hospital of Xuzhou Medical University, Xuzhou 221004, China
| | - Chaoyong Xiao
- Department of Medical Imaging, Nanjing Brain Hospital, Nanjing 210029, China
| | - Feng Chen
- Department of Medical Imaging, Hainan General Hospital, Hainan 570311, China
| | - Tao Liu
- Department of Neurology, Hainan General Hospital, Haikou 570311, China
| | - Hongmei Gu
- Department of Medical Imaging, Affiliated Hospital of Nantong University, Nantong 226001, China
| | - Wei Xing
- Department of Medical Imaging, The first people's hospital of Changzhou. Changzhou 213200, China
| | - Guangming Lu
- Department of Diagnostic Radiology, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, China; School of Medical Imaging, Xuzhou Medical University, Xuzhou 221004, China
| | - Zhiqiang Zhang
- Department of Diagnostic Radiology, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, China; School of Medical Imaging, Xuzhou Medical University, Xuzhou 221004, China.
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Ballout AA, Oh SY, Huang B, Patsalides A, Libman RB. Ghost infarct core: A systematic review of the frequency, magnitude, and variables of CT perfusion overestimation. J Neuroimaging 2023; 33:716-724. [PMID: 37248074 DOI: 10.1111/jon.13127] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND AND PURPOSE CT perfusion (CTP) imaging is now widely used to select patients with large vessel occlusions for mechanical thrombectomy. Ghost infarct core (GIC) phenomenon has been coined to describe CTP core overestimation and has been investigated in several retrospective studies. Our aim is to review the frequency, magnitude, and variables associated with this phenomenon. METHODS A primary literature search resulted in eight studies documenting median time from symptom onset to CTP, median estimated core size, median final infarct volume, median core overestimation of the GIC population, recanalization rates, good outcomes, and collateral status for this systematic review. RESULTS All the studies investigated patients who underwent CTP within 6 hours of symptom onset, ranging from median times of 105 to 309 minutes. The frequency of core overestimation varied from 6% to 58.4%, while the median estimated ischemic core and final infarction volume ranged from 7 to 27 mL and 12 to 31 mL, respectively. The median core overestimation ranged from 3.6 to 30 mL with upper quartile ranges up to 58 mL. GIC was found to be a highly time-and-collateral-dependent process that increases in frequency and magnitude as the time from symptom onset to imaging decreases and in the presence of poor collaterals. CONCLUSIONS CTP ischemic core overestimation appears to be a relatively common phenomenon that is most frequent in patients with poor collaterals imaged within the acute time window. Early perfusion imaging should be interpreted with caution to prevent the inadvertent exclusion of patients from highly effective reperfusion therapies.
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Affiliation(s)
- Ahmad A Ballout
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Seok Yoon Oh
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Brendan Huang
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Athos Patsalides
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Richard B Libman
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
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Mubarak F, Fatima H, Mustafa MS, Shafique MA, Abbas SR, Rangwala HS. Assessment Precision of CT Perfusion Imaging in the Detection of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e44396. [PMID: 37791142 PMCID: PMC10542215 DOI: 10.7759/cureus.44396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 10/05/2023] Open
Abstract
Stroke, a prevalent medical emergency, comprises ischemic and hemorrhagic subtypes, with acute ischemic stroke (AIS) being a predominant type. The application of computed tomography perfusion (CTP) imaging has gained prominence due to its rapidity and accessibility in stroke evaluation. This study systematically reviews and conducts a meta-analysis of existing literature to assess the diagnostic accuracy of CTP in detecting AIS and predicting hemorrhagic transformation (HT). Employing Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, an extensive search was conducted across electronic databases and relevant radiology journals. Studies conducted between 2007 and 2023 that fulfilled predetermined inclusion criteria underwent quality assessment using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS 2) tool. Cochrane diagnostic accuracy tools were used for data extraction. Thirteen studies involving a total of 1014 patients were included in the analysis. The diagnostic performance of CTP in predicting HT demonstrated high sensitivity (86.7%) and moderate specificity (77.8%), resulting in an overall accuracy of 79.1%. The negative predictive value (NPV) was notably high (92.9%), signifying its efficacy in excluding patients at risk of HT. The positive predictive value (PPV) was comparatively lower (60.3%), highlighting the need for clinical context when making thrombolysis decisions. The false positive rate was 16.2%, while the false negative rate was minimal (9.8%). Subgroup analysis underscored consistent sensitivity and specificity across diverse imaging metrics. The findings of this study emphasize the promising diagnostic accuracy of CTP imaging in predicting HT subsequent to AIS. This non-invasive technique can aid treatment decisions and patient management strategies. By effectively assessing perfusion status and offering predictive insights, CTP imaging improves stroke intervention choices, especially in identifying patients with a lower risk of HT.
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Affiliation(s)
- Fatima Mubarak
- Department of Radiology, Aga Khan University Hospital, Karachi, PAK
| | - Hareer Fatima
- Department of Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | | | | | - Syed Raza Abbas
- Department of Medicine, Dow University of Health Sciences, Karachi, PAK
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Nagy SA, Ivic I, Tóth P, Komoly S, Kiss T, Pénzes M, Málnási-Csizmadia A, Dóczi T, Perlaki G, Orsi G. Post-reperfusion acute MR diffusion in stroke is a potential predictor for clinical outcome in rats. Sci Rep 2023; 13:5598. [PMID: 37019923 PMCID: PMC10076321 DOI: 10.1038/s41598-023-32679-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 03/31/2023] [Indexed: 04/07/2023] Open
Abstract
Middle cerebral artery occlusion (MCAO) models show substantial variability in outcome, introducing uncertainties in the evaluation of treatment effects. Early outcome predictors would be essential for prognostic purposes and variability control. We aimed to compare apparent diffusion coefficient (ADC) MRI data obtained during MCAO and shortly after reperfusion for their potentials in acute-phase outcome prediction. Fifty-nine male rats underwent a 45-min MCAO. Outcome was defined in three ways: 21-day survival; 24 h midline-shift and neurological scores. Animals were divided into two groups: rats surviving 21 days after MCAO (survival group, n = 46) and rats dying prematurely (non-survival/NS group, n = 13). At reperfusion, NS group showed considerably larger lesion volume and lower mean ADC of the initial lesion site (p < 0.0001), while during occlusion there were no significant group differences. At reperfusion, each survival animal showed decreased lesion volume and increased mean ADC of the initial lesion site compared to those during occlusion (p < 10-6), while NS group showed a mixed pattern. At reperfusion, lesion volume and mean ADC of the initial lesion site were significantly associated with 24 h midline-shift and neurological scores. Diffusion MRI performed soon after reperfusion has a great impact in early-phase outcome prediction, and it works better than the measurement during occlusion.
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Affiliation(s)
- Szilvia Anett Nagy
- ELKH-PTE Clinical Neuroscience MR Research Group, Ret Str. 2, 7623, Pecs, Hungary.
- Pecs Diagnostic Centre, Rét Street 2, 7623, Pecs, Hungary.
- Structural Neurobiology Research Group, Szentágothai Research Centre, University of Pecs, Ifjúság Street 20, 7624, Pecs, Hungary.
- Department of Neurology, Medical School, University of Pecs, Rét Street 2, 7623, Pecs, Hungary.
| | - Ivan Ivic
- Pecs Diagnostic Centre, Rét Street 2, 7623, Pecs, Hungary
- Selvita d.o.o., Prilaz Baruna Filipovića 29, 10000, Zagreb, Croatia
| | - Péter Tóth
- ELKH-PTE Clinical Neuroscience MR Research Group, Ret Str. 2, 7623, Pecs, Hungary
- Department of Neurosurgery, Medical School, University of Pecs, Rét Street 2, 7623, Pecs, Hungary
| | - Sámuel Komoly
- Department of Neurology, Medical School, University of Pecs, Rét Street 2, 7623, Pecs, Hungary
| | - Tamás Kiss
- Szentágothai Research Centre, University of Pecs, Ifjúság Street 20, Pecs, Hungary
| | - Máté Pénzes
- Department of Biochemistry, Eötvös Loránd University, Pázmány Péter Sétány 1/C, 1117, Budapest, Hungary
- Motorpharma Ltd., Szilágyi E. Fasor 27, 1026, Budapest, Hungary
| | - András Málnási-Csizmadia
- Motorpharma Ltd., Szilágyi E. Fasor 27, 1026, Budapest, Hungary
- ELKH-ELTE Motor Pharmacology Research Group, Department of Biochemistry, Eötvös Loránd University, Pázmány Péter Sétány 1/C, 1117, Budapest, Hungary
| | - Tamás Dóczi
- Pecs Diagnostic Centre, Rét Street 2, 7623, Pecs, Hungary
- Department of Neurosurgery, Medical School, University of Pecs, Rét Street 2, 7623, Pecs, Hungary
| | - Gábor Perlaki
- ELKH-PTE Clinical Neuroscience MR Research Group, Ret Str. 2, 7623, Pecs, Hungary
- Pecs Diagnostic Centre, Rét Street 2, 7623, Pecs, Hungary
- Department of Neurology, Medical School, University of Pecs, Rét Street 2, 7623, Pecs, Hungary
- Department of Neurosurgery, Medical School, University of Pecs, Rét Street 2, 7623, Pecs, Hungary
| | - Gergely Orsi
- ELKH-PTE Clinical Neuroscience MR Research Group, Ret Str. 2, 7623, Pecs, Hungary
- Pecs Diagnostic Centre, Rét Street 2, 7623, Pecs, Hungary
- Department of Neurology, Medical School, University of Pecs, Rét Street 2, 7623, Pecs, Hungary
- Department of Neurosurgery, Medical School, University of Pecs, Rét Street 2, 7623, Pecs, Hungary
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Sun H, Wu Y, Liu N, Long M, Liu G, Sun PZ, Yin J. Tissue perfusion of the kurtosis/diffusion mismatch differs from the central core and peripheral regions in acute cerebral infarction patients. Acta Radiol 2023; 64:1155-1165. [PMID: 35765208 DOI: 10.1177/02841851221109678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite its wide adoption in stroke imaging, the diffusion-weighted imaging (DWI) lesion is heterogeneous. The emerging diffusion kurtosis imaging (DKI) has been postulated to resolve the graded DWI lesion. PURPOSE To determine the perfusion characteristics of the central infarction core, kurtosis/diffusion mismatch, and peripheral regions. MATERIAL AND METHODS Patients with acute ischemic stroke underwent DWI, DKI, and perfusion-weighted imaging (PWI) scans. The patients were divided into mean kurtosis (MK)/mean diffusivity (MD) match and mismatch groups. Perfusion parameters were measured in the MK/MD lesion and peripheral areas in the MK/MD match group. We also analyzed perfusion status in the MK/MD lesion mismatch area for the mismatch group. RESULTS A total of 40 eligible patients (24 MK/MD match and 16 MK/MD mismatch) were enrolled in the final data analysis. The MTT and TTP progressively decreased, while the cerebral blood flow (CBF) and cerebral blood volume (CBV) increased from the central to peripheral areas. In addition, CBF in the MK/MD mismatch region was significantly higher than that in the central region (P < 0.05), but similar to the peripheral region. Furthermore, CBV in the MK/MD mismatch region did not differ significantly from that of the central region, but both were significantly lower than that of the peripheral area (P < 0.05). CONCLUSION The MK/MD mismatch region had blood flow similar to the peripheral region but with a reduced blood volume, indicating that it was less ischemic from the infarction core, albeit insufficient collateral circulation.
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Affiliation(s)
- Haizhen Sun
- Department of Radiology, Tianjin Medical University Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin, PR China
- NHC Key Laboratory of Hormones and Development (Tianjin Medical University), Tianjin Key Laboratory of Metabolic Diseases, Tianjin, PR China
| | - Yalin Wu
- The First Central Clinical College of Tianjin Medical University, Tianjin, PR China
| | - Na Liu
- The First Central Clinical College of Tianjin Medical University, Tianjin, PR China
| | - Miaomiao Long
- Department of Radiology, 66571Tianjin First Central Hospital, Tianjin Medical Imaging Institution, Tianjin, PR China
| | - Guoping Liu
- Department of Neurology, 66571Tianjin First Central Hospital, Tianjin, PR China
| | - Phillip Zhe Sun
- Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, Atlanta, GA, USA
- Department of Radiology and Imaging Sciences, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Jianzhong Yin
- Department of Radiology, 66571Tianjin First Central Hospital, Tianjin Medical Imaging Institution, Tianjin, PR China
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10
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ADC measurement relevance to predict hemorrhage transformation after mechanical thrombectomy. J Neurol Sci 2022; 441:120370. [DOI: 10.1016/j.jns.2022.120370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/11/2022] [Accepted: 07/27/2022] [Indexed: 11/20/2022]
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11
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Ng FC, Churilov L, Yassi N, Kleinig TJ, Thijs V, Wu TY, Shah DG, Dewey HM, Sharma G, Desmond PM, Yan B, Parsons MW, Donnan GA, Davis SM, Mitchell PJ, Leigh R, Campbell BCV. Reduced Severity of Tissue Injury Within the Infarct May Partially Mediate the Benefit of Reperfusion in Ischemic Stroke. Stroke 2022; 53:1915-1923. [PMID: 35135319 DOI: 10.1161/strokeaha.121.036670] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Emerging data suggest tissue within the infarct lesion is not homogenously damaged following ischemic stroke but has a gradient of injury. Using blood-brain-barrier (BBB) disruption as a marker of tissue injury, we tested whether therapeutic reperfusion improves clinical outcome by reducing the severity of tissue injury within the infarct in patients with ischemic stroke. METHODS In a pooled analysis of patients treated for anterior circulation large vessel occlusion in the EXTEND-IA TNK (Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke) and EXTEND-IA part-2 (Determining the Optimal Dose of Tenecteplase Before Endovascular Therapy for Ischaemic Stroke) trials, post-treatment BBB permeability at 24 hours was calculated based on the extent of T1-brightening by extravascular gadolinium on T2* perfusion-weighted imaging and measured within the diffusion-weighted-imaging lesion. First, to determine the clinical significance of BBB disruption as a marker of severity of tissue injury, we examined the association between post-treatment BBB permeability and functional outcome. Second, we performed an exploratory (reperfusion, BBB permeability, functional outcome) mediation analysis to estimate the proportion of the reperfusion-outcome relationship that is mediated by change in BBB permeability. RESULTS In the 238 patients analyzed, an increased BBB permeability measured within the infarct at 24 hours was associated with a reduced likelihood of favorable outcome (90-day modified Rankin Scale score of ≤2) after adjusting for age, baseline National Institutes of Health Stroke Scale, premorbid modified Rankin Scale, infarct topography, laterality, thrombolytic agent, sex, parenchymal hematoma, and follow-up infarct volume (adjusted odds ratio, 0.86 [95% CI, 0.75-0.98], P=0.023). Mediation analysis suggested reducing the severity of tissue injury (as estimated by BBB permeability) accounts for 18.2% of the association between reperfusion and favorable outcome, as indicated by a reduction in the regression coefficient of reperfusion after addition of BBB permeability as a covariate. CONCLUSIONS In patients with ischemic stroke, reduced severity of tissue injury within the infarct, as determined by assessing the integrity of the BBB, is independently associated with improved functional outcome. In addition to reducing diffusion-weighted imaging-defined infarct volume, reperfusion may also improve clinical outcome by reducing tissue injury severity within the infarct.
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Affiliation(s)
- Felix C Ng
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.).,Department of Neurology, Austin Hospital, Austin Health, Heidelberg, Australia (F.C.N., V.T.)
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.).,The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia. (L.C., V.T., B.C.V.C.).,Melbourne Medical School, The University of Melbourne, Heidelberg, Victoria, Australia (L.C.)
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.).,Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia (N.Y.)
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Australia (T.J.K.)
| | - Vincent Thijs
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia. (L.C., V.T., B.C.V.C.).,Department of Neurology, Austin Hospital, Austin Health, Heidelberg, Australia (F.C.N., V.T.)
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, New Zealand (T.Y.W.)
| | - Darshan G Shah
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia (D.G.S.)
| | - Helen M Dewey
- Eastern Health and Eastern Health Clinical School, Department of Neurosciences, Monash University, Clayton, Australia (H.M.D.)
| | - Gagan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.)
| | - Patricia M Desmond
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (P.M.D., B.Y., P.J.M.)
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.).,Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (P.M.D., B.Y., P.J.M.)
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.)
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.)
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (P.M.D., B.Y., P.J.M.)
| | - Richard Leigh
- Department of Neurology, John Hopkins University, Baltimore, MD (R.L.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.S., S.M.D., B.C.V.C.).,The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia. (L.C., V.T., B.C.V.C.)
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12
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Sun PZ. Consistent depiction of the acidic ischemic lesion with APT MRI-Dual RF power evaluation of pH-sensitive image in acute stroke. Magn Reson Med 2022; 87:850-858. [PMID: 34590730 PMCID: PMC8627494 DOI: 10.1002/mrm.29029] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/31/2021] [Accepted: 09/09/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE Amide proton transfer-weighted (APTw) MRI provides a non-invasive pH-sensitive image, complementing perfusion and diffusion imaging for refined stratification of ischemic tissue. Although the commonly used magnetization transfer (MT) asymmetry (MTRasym ) calculation reasonably corrects the direct RF saturation effect, it is susceptible to the concomitant semisolid macromolecular MT contribution. Therefore, this study aimed to compare the performance of MTRasym and magnetization transfer and relaxation-normalized APT (MRAPT) analyses under 2 representative experimental conditions. METHODS Multiparametric MRI scans were performed in a rodent model of acute stroke, including relaxation, diffusion, and Z spectral images under 2 representative RF levels of 0.75 and 1.5 µT. Both MTRasym and MRAPT values in the ischemic diffusion lesion and the contralateral normal areas were compared using correlation and Bland-Altman tests. In addition, the acidic lesion volumes were compared. RESULTS MRAPT measurements from the diffusion lesion under the 2 conditions were highly correlated (R2 = 0.97) versus MTRasym measures (R2 = 0.58). The pH lesion sizes determined from MRAPT analysis were in good agreement (178 ± 43 mm3 vs. 186 ± 55 mm3 for B1 of 0.75 and 1.5 µT, respectively). CONCLUSIONS The study demonstrated that MRAPT analysis could be generalized to moderately different RF amplitudes, providing a more consistent depiction of acidic lesions than the MTRasym analysis.
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Affiliation(s)
- Phillip Zhe Sun
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA,Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, Atlanta GA,Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta GA,Corresponding Author: Phillip Zhe Sun, Ph.D., Department of Radiology and Imaging Sciences, Emory University School of Medicine, 954 Gatewood Road NE, Atlanta, GA 30329, Phone: (404) 727-7786; (404) 712-1667,
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13
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Turtzo LC, Luby M, Jikaria N, Griffin AD, Greenman D, Bokkers RPH, Parikh G, Peterkin N, Whiting M, Latour LL. Cytotoxic Edema Associated with Hemorrhage Predicts Poor Outcome after Traumatic Brain Injury. J Neurotrauma 2021; 38:3107-3118. [PMID: 34541886 DOI: 10.1089/neu.2021.0037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Magnetic resonance imaging (MRI) is used rarely in the acute evaluation of traumatic brain injury (TBI) but may identify findings of clinical importance not detected by computed tomography (CT). We aimed to characterize the association of cytotoxic edema and hemorrhage, including traumatic microbleeds, on MRI obtained within hours of acute head trauma and investigated the relationship to clinical outcomes. Patients prospectively enrolled in the Traumatic Head Injury Neuroimaging Classification study (NCT01132937) with evidence of diffusion-related findings or hemorrhage on neuroimaging were included. Blinded interpretation of MRI for diffusion-weighted lesions and hemorrhage was conducted, with subsequent quantification of apparent diffusion coefficient (ADC) values. Of 161 who met criteria, 82 patients had conspicuous hyperintense lesions on diffusion-weighted imaging (DWI) with corresponding regions of hypointense ADC in proximity to hemorrhage. Median time from injury to MRI was 21 (10-30) h. Median ADC values per patient grouped by time from injury to MRI were lowest within 24 h after injury. The ADC values associated with hemorrhagic lesions are lowest early after injury, with an increase in diffusion during the subacute period, suggesting transformation from cytotoxic to vasogenic edema during the subacute post-injury period. Of 118 patients with outcome data, 60 had Glasgow Outcome Scale Extended scores ≤6 at 30/90 days post-injury. Cytotoxic edema on MRI (odds ratio [OR] 2.91 [1.32-6.37], p = 0.008) and TBI severity (OR 2.51 [1.32-4.74], p = 0.005) were independent predictors of outcome. These findings suggest that in patients with TBI who had findings of hemorrhage on CT, patients with DWI/ADC lesions on MRI are more likely to do worse.
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Affiliation(s)
- L Christine Turtzo
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Marie Luby
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Neekita Jikaria
- Center for Neuroscience and Regenerative Medicine, Bethesda, Maryland, USA
| | | | - Danielle Greenman
- Center for Neuroscience and Regenerative Medicine, Bethesda, Maryland, USA
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gunjan Parikh
- R Adams Shock Trauma Center and University of Maryland School of Medicine, Baltimore, Maryland, USA.,Division of Neurocritical Care and Emergency Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nicole Peterkin
- Center for Neuroscience and Regenerative Medicine, Bethesda, Maryland, USA
| | - Mark Whiting
- Center for Neuroscience and Regenerative Medicine, Bethesda, Maryland, USA
| | - Lawrence L Latour
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA.,Center for Neuroscience and Regenerative Medicine, Bethesda, Maryland, USA
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14
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Cheung J, Doerr M, Hu R, Sun PZ. Refined Ischemic Penumbra Imaging with Tissue pH and Diffusion Kurtosis Magnetic Resonance Imaging. Transl Stroke Res 2021; 12:742-753. [PMID: 33159656 PMCID: PMC8102648 DOI: 10.1007/s12975-020-00868-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 10/14/2020] [Accepted: 10/18/2020] [Indexed: 12/19/2022]
Abstract
Imaging has played a vital role in our mechanistic understanding of acute ischemia and the management of acute stroke patients. The most recent DAWN and DEFUSE-3 trials showed that endovascular therapy could be extended to a selected group of late-presenting stroke patients with the aid of imaging. Although perfusion and diffusion MRI have been commonly used in stroke imaging, the approximation of their mismatch as the penumbra is oversimplified, particularly in the era of endovascular therapy. Briefly, the hypoperfusion lesion includes the benign oligemia that does not proceed to infarction. Also, with prompt and effective reperfusion therapy, a portion of the diffusion lesion is potentially reversible. Therefore, advanced imaging that provides improved ischemic tissue characterization may enable new experimental stroke therapeutics and eventually further individualize stroke treatment upon translation to the clinical setting. Specifically, pH imaging captures tissue of altered metabolic state that demarcates the hypoperfused lesion into ischemic penumbra and benign oligemia, which remains promising to define the ischemic penumbra's outer boundary. On the other hand, diffusion kurtosis imaging (DKI) differentiates the most severely damaged and irreversibly injured diffusion lesion from the portion of diffusion lesion that is potentially reversible, refining the inner boundary of the penumbra. Altogether, the development of advanced imaging has the potential to not only transform the experimental stroke research but also aid clinical translation and patient management.
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Affiliation(s)
- Jesse Cheung
- Emory College of Arts and Sciences, Emory University, Atlanta, GA, 30329, USA
- Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, Atlanta, GA, 30329, USA
| | - Madeline Doerr
- Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, Atlanta, GA, 30329, USA
- Dartmouth College, Hanover, NH, 03755, USA
| | - Ranliang Hu
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton RD NE, Atlanta, GA, 30322, USA
| | - Phillip Zhe Sun
- Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, Atlanta, GA, 30329, USA.
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton RD NE, Atlanta, GA, 30322, USA.
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15
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Kim BJ, Menon BK, Kim JY, Shin DW, Baik SH, Jung C, Han MK, Demchuk A, Bae HJ. Endovascular Treatment After Stroke Due to Large Vessel Occlusion for Patients Presenting Very Late From Time Last Known Well. JAMA Neurol 2020; 78:2769023. [PMID: 32777014 PMCID: PMC7418043 DOI: 10.1001/jamaneurol.2020.2804] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/19/2020] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Endovascular treatment (EVT) after ischemic stroke due to emergent large vessel occlusion is usually constrained by a specific window of less than 16 to 24 hours from the time the patient was last known well (LKW). Patients with slow progression and tenacious collateral circulation may persist beyond 16 hours. OBJECTIVES To estimate the prevalence of salvageable tissues 16 hours or more from LKW after ischemic stroke due to emergent large vessel occlusion and investigate the effectiveness of EVT in delayed large vessel occlusion. DESIGN, SETTING AND PARTICIPANTS In this case-control study, from a total of 8032 patients with stroke or transient ischemic attack who were admitted between January 1, 2012, and December 31, 2018, to a single referral university hospital, 150 patients were retrospectively identified who had an acute ischemic stroke with internal carotid artery or middle cerebral artery occlusion, had a baseline National Institutes of Health Stroke Scale score of 6 or more, and arrived 16 hours or more from time LKW. The decision for EVT was made by a treating physician according to the institutional protocol. MAIN OUTCOMES AND MEASURES Baseline ischemic core, collateral circulation status, and computed tomographic or magnetic resonance perfusion parameters were retrospectively quantified. Follow-up images, evaluated a median of 93 hours (interquartile range, 66-120 hours) after arrival, were used to assess the final infarct and hemorrhagic transformation. The main outcome was the modified Rankin Scale score at 90 days. RESULTS For 150 patients (81 men [54%]; mean [SD] age at onset, 70.1 [13.0] years; median National Institutes of Health Stroke Scale score, 12 [interquartile range, 8-18]), the median ischemic core volume was 11.5 mL (interquartile range, 0-39.1 mL), the median penumbra volume (>6 seconds) was 55.0 mL (interquartile range, 15-128 mL), and the median mismatch ratio was 4.0 (interquartile range, 0.9-18.3). By the imaging inclusion criteria for EVT trials, there were 50 DAWN (DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake-up and Late Presenting Strokes Undergoing Neurointervention With Trevo)-eligible patients (33%), 58 DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke)-eligible patients (39%), and 57 ESCAPE (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times)-eligible patients (38%). Endovascular treatment was performed for 24 patients (16%). In propensity score-matched analyses, EVT was associated with better odds of a 90-day modified Rankin Scale score of 0 to 2 (adjusted odds ratio, 11.08 [95% CI, 1.88-108.60]) and a 90-day modified Rankin Scale score shift (common adjusted odds ratio, 5.17 [95% CI, 1.80-15.62]). Type 2 parenchymal hemorrhage was seen in 3 of 24 patients (13%) who received EVT and in 4 of 126 patients (3%) who received medical management (adjusted odds ratio, 4.06 [95% CI, 0.63-26.30]). In a subgroup of 109 patients who were 24 hours from time LKW, EVT was associated with a favorable mRS shift (common adjusted odds ratio, 10.54 [95% CI, 2.18-59.34]). CONCLUSIONS AND RELEVANCE This study suggests that patients with anterior circulation large vessel occlusion presenting very late (>16 hours to 10 days) from the time they were LKW may benefit from EVT.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Bijoy K. Menon
- Department of Clinical Neurosciences and Radiology, Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jun Yup Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Dong-Woo Shin
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Sung Hyun Baik
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Moon-Ku Han
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Andrew Demchuk
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
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16
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Moshayedi P, Saber H, Liebeskind DS. Is there Still a Time Window in the Treatment of Acute Stroke? Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00628-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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17
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Premilovac D, Blackwood SJ, Ramsay CJ, Keske MA, Howells DW, Sutherland BA. Transcranial contrast-enhanced ultrasound in the rat brain reveals substantial hyperperfusion acutely post-stroke. J Cereb Blood Flow Metab 2020; 40:939-953. [PMID: 32063081 PMCID: PMC7181087 DOI: 10.1177/0271678x20905493] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Direct and real-time assessment of cerebral hemodynamics is key to improving our understanding of cerebral blood flow regulation in health and disease states such as stroke. While a number of sophisticated imaging platforms enable assessment of cerebral perfusion, most are limited either spatially or temporally. Here, we applied transcranial contrast-enhanced ultrasound (CEU) to measure cerebral perfusion in real-time through the intact rat skull before, during and after ischemic stroke, induced by intraluminal filament middle cerebral artery occlusion (MCAO). We demonstrate expected decreases in cortical and striatal blood volume, flow velocity and perfusion during MCAO. After filament retraction, blood volume and perfusion increased two-fold above baseline, indicative of acute hyperperfusion. Adjacent brain regions to the ischemic area and the contralateral hemisphere had increased blood volume during MCAO. We assessed our data using wavelet analysis to demonstrate striking vasomotion changes in the ischemic and contralateral cortices during MCAO and reperfusion. In conclusion, we demonstrate the application of CEU for real-time assessment of cerebral hemodynamics and show that the ischemic regions exhibit striking hyperemia post-MCAO. Whether this post-stoke hyperperfusion is sustained long-term and contributes to stroke severity is not known.
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Affiliation(s)
- Dino Premilovac
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Sarah J Blackwood
- Åstrand Laboratory of Work Physiology, Swedish School of Sport and Health Sciences, GIH, Stockholm, Sweden
| | - Ciaran J Ramsay
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Michelle A Keske
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, Victoria, Australia
| | - David W Howells
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Brad A Sutherland
- School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
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